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DAPT with aspirin plus clopidogrel for 30 days is the best option after minor stroke or TIA
Clinical Question
What is the balance of benefits and harms for dual antiplatelet therapy compared with monotherapy for the secondary prevention of ischemic stroke?
Bottom line
For patients with minor stroke or TIA, DAPT with aspirin plus clopidogrel for up to 30 days reduces the likelihood of subsequent stroke (NNT = 50) more than monotherapy with aspirin, with a small increase in the risk of major hemorrhage (NNTH = 500). A longer duration of therapy increases the risk of harm without increasing the likelihood of benefit. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Outpatient (any)
Synopsis
These authors identified randomized trials that compared dual antiplatelet therapy (DAPT) with monotherapy started within 3 days of the index stroke or transient ischemic attack (TIA). In some cases, the researchers were able to get data for the subset of patients who were randomized within 3 days from studies where longer intervals were allowed between stroke and randomization. The search was comprehensive, and the analysis was methodologically sound. The final analysis included 17 studies with a total of 27,358 patients. The mean age of participants was 65 years, approximately two-thirds were men, and most studies targeted patients with minor ischemic stroke or TIA. The studies were assessed to be at low risk of bias. Monotherapy was with aspirin in 15 studies; the other 2 studies used clopidogrel monotherapy. The most common DAPT regimen was aspirin plus clopidogrel. The largest study (THALES) compared aspirin alone with aspirin plus ticagrelor and, because of its size, the authors did sensitivity analyses with and without this trial. Overall, using DAPT instead of monotherapy for 30 days or less resulted in 20 fewer strokes (number needed to treat [NNT] = 50) and 2 more major hemorrhages (number needed to treat to harm [NNTH] = 500) per 1000 persons. The likelihood of major hemorrhage was the same when the THALES trial was excluded, although there was no longer a significant difference in the risk of hemorrhage between aspirin and DAPT groups. The authors stratified the analysis by more than 30 days or 30 days or less of treatment. Although the benefit was similar for a treatment duration of up to 30 days, the risk of hemorrhage was greater with longer duration therapy.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA